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  1. Downloaded from http://ard.bmj.com/ on May 31, 2017 - Published by group.bmj.com Annals ofthe Rheumatic Diseases, 1981, 40, 90-91 Case report Sausage digit due to radish bacillus E. C. HUSKISSON, D. V. DOYLE, E. FIONA FOWLER, AND ELIZABETH J. SHAW From the Departments ofRheumatology andPathology, St Bartholomew's Hospital, London ECIA 7BE SUMMARY We wish to draw attention to a very characteristic but little known syndrome. An elderly woman presented with a 'sausage finger', rheumatological jargon used to describe diffuse swelling of the digit. This proved to be a proliferative tenosynovitis caused by an atypical mycobacterium, Mycobacterium terrae, or the radish bacillus. Case report Discussion This case presented a serious diagnostic challenge to clinicians and pathologists, though the condition is well described in the literature. Kelly et al.12 described 19 cases of atypical mycobacterial infec- tion in orthopaedic practice, of which 11 involved tendons. They emphasised the frequency of local trauma as the portal of entry of the organism. For example, 2 of their patients were involved in killing or cleaning chickens and became infected with Mycobacterium avium. Injection of cortico- steroids also appeared ducing the organism. Excision of the involved tendon sheath was sufficient treatment in most cases. Mycobacterium terrae was considered to be non- pathogenic until Edwards et al.3 described an infec- tion in a patient with Fanconi's pancytopenia. This patient presented like ours, with a swollen ery- thematosus forefinger which ascribed to rheumatoid arthritis, since it was treated with anti-inflammatory drugs, corticosteroids, and gold. Sixteen months later the wrist became involved with a chronic proliferative synovitis, and it was only after synovectomy that the diagnosis was made. Hall et al.4 reported another case, again presenting with a painful swollen finger. In our case the atypical mycobacterium pre- sumably gained entry via the prick of the thorn, as M. terrae can be found in soil and vegetables. It was first isolated from radish washings. This typeof infection must therefore be added to the list of known rheumatological hazards of gardening. They include plant thorn synovitis and sporotrichosis as well as more obvious disasters like backache and tennis elbow. Mysterious proliferative tenosynovitis, A 66-year-old woman presented with a 5 week history ofpain and swelling ofthe right index finger. She was a keen gardener and remembered pricking her finger with a blackberry thorn 6 months earlier. Thefingerhad been swollen for 1 week but had settled spontaneously. She had a past history of localised follicular lymphoma treated by radiotherapy. She had remained free of recurrence for 6 years, and there was no other evidence that she was immuno- compromised. Examination revealed a sausage digit with diffuse swelling, warmth, and tenderness. A diagnosis of flexor tenosynovitis was made and shewas treated with indomethacin. This produced no benefit and the finger was therefore explored. At operation there was a florid proliferative tenosyno- vitis, and extensive synovectomy was carried out. She made an uneventful recovery, and good but not full flexion of her index finger was achieved. Histological examination of the tendon sheath showed an active chronic tenosynovitis. There was extensive fibrinous deposition within the sheath, with surrounding granulomatous composed predominantly epithelioid histocytes. There was necrosis. A modified Ziehl-Neelsen stain (Wade- Fite) revealed several small groups ofacid-fast bacilli which were shorter and thicker than typical Myco- bacterium tuberculosis. Cultures of the excised tissue grew Mycobacterium terrae. to be capable of intro- presumably was inflammation lymphocytes no and of caseation Accepted for publication 14 March 1980 Correspondence to Dr E. C. Huskisson, Department of Rheumatology, St Bartholomew's Hospital, West Smithfield, London ECIA 7BE. 90

  2. Downloaded from http://ard.bmj.com/ on May 31, 2017 - Published by group.bmj.com Sausage digit due to radish bacillus 91 bacilli other than tubercle bacilli. J Bone Joint Surg 1963; 45A: 327-36. Kelly P J, Karlson A G, Weed, L A Lipscomb P R. Infection of synovial tissue by mycobacteria other than Mycobacterium tuberculosis. J Bone Joint Surg 1967; 49A: 1521-30. 3 Edwards M S, Huber T W, Baker C J. Mycobacterium terrae synovitis and osteomyelitis. Am Rev Resp Dis 1978; 117: 161-3. 4 Hall J T, Gould J A, Hardin J G. Chronic tenosynovial hand infection from Mycobacterium Rheum 1979; 22: 1386-90. like mysterious proliferative synovitis in a joint, deserves biopsy for histological and bacteriological examination. We are grateful to Dr C Dulake and Mr C. H. Collins of the Public Health Laboratory, Dulwich, for identification of Mycobacterium terrae. 2 References 1KellyPJ, WeedL A, Lipscomb P R. Infection of tendon sheaths, bursea, joints and soft tissues by acid-fast terrae. Arthritis

  3. Downloaded from http://ard.bmj.com/ on May 31, 2017 - Published by group.bmj.com Sausage digit due to radish bacillus. E C Huskisson, D V Doyle, E F Fowler and E J Shaw Ann Rheum Dis 1981 40: 90-91 doi: 10.1136/ard.40.1.90 Updated information and services can be found at: http://ard.bmj.com/content/40/1/90 These include: Receive free email alerts when new articles cite this Email alerting article. Sign up in the box at the top right corner of the service online article. Notes To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/